NATIONAL BANK OF PAKISTAN

AUTOMATIC BANK DRAFT AUTHORIZATION FORM

MAAZ ALTAF NAGARIA 42000-6030445-5/JUNAID TEA

Policy Number(s)
DEMAND CHQ PAY

TEN LAC AND THIRTY FIVE THOUSAND ONLY

Amount
Name ofinPolicy
Words Owner(s)

Rs=1,035,000/= 15-02-2022
Street
AMOUNT Address Daytime Phone Number
DATE

KARACHI SINDH 784000 6955004

City State Zip Code CHQ #
Nighttime Phone Number

By completing this automatic bank draft authorization, I/we hereby authorize The Great-West Life Assurance Company and/or Great-
West Life & Annuity Insurance Company to make monthly withdrawals from my/our __ Checking Acount / ___ Savings Account
(select one) maintained at the named banking institution listed below for my/our policy(ies). I/we acknowledge that the origination of the
ACH transactions to my/our bank account must comply with the provisions of U.S. law.

Bank Name ABA Routing Number Account Number

Branch Name of Account Holder Bank Address

I/we understand that this agreement may be terminated and/or changed by providing written notice to The Great-West Life Assurance
Company and/or Great-West Life & Annuity Insurance Company a minimum of 30 business days prior to the withdrawal date.

DEMAND PAY
Automatic ORDERInstructions
Payment
15-2-2022
Withdrawal Date: ___________________ ** Withdrawal will be effective the 1st of each month unless otherwise specified **

PAYMENT CHQ AMOUNT

Universal Life/Annuity ______________________
monthly
Rs=1,035,000/=
withdrawal amount $ ______________________
I/we have attached a copy of a voided check for the above referenced account
**Note: A voided check is required to setup monthly autopay**
*--------------------------------------TEN LAC AND THIRTY FIVE THOUSAND ONLY----------------------------------------------*

If the undersigned is signing in a representative capacity, the undersigned warrants that he or she has the authority to bind the
entity on whose behalf this document is being executed.

Account Holder Signature Printed Name Date

Account Holder Signature Printed Name Date

NATIONAL BANK
GREAT-WEST OF&PAKISTAN
LIFE ANNUITY INSURANCE COMPANY
THE GREAT-WEST LIFE ASSURANCE COMPANY
PO Box 85056
Lincoln, NE 68501-5056

(02/01/2014) REG 1 of 1